Health Information For Patients and the Community

Following a Gluten-Free Diet for the Treatment of Celiac Disease

Why do I need to follow a gluten-free diet? If you have a confirmed diagnosis of celiac disease, your doctor may have told you that you should follow a strict and life-long gluten-free diet.(1) This means avoiding all foods that contain or have come in contact with wheat, barley, or rye ingredients.(1) Research shows that ingesting gluten-containing foods triggers an autoimmune response that can damage your intestinal lining.(2) The damage can lead to a wide variety of symptoms that can affect your overall health, so it is important that you understand how to follow a gluten- free diet.(2) This handout will provide you with the tools you need to live a happy and healthy gluten-free lifestyle.

Gluten-Free Diet Gluten-Free Flour Recipe Grains and starches allowed • 1 cup potato starch • 1 cup soya flour Amaranth • ½ cup tapioca flour/ starch Arrowroot • ½ teaspoon xanthan gum Buckwheat Corn Measure and combine above ingredients. One cup is Flax equal to one cup regular flour. Flours made from nuts, beans, and seeds Potato starch must be used, NOT flour. Xanthan gum Millet adds moisture, which is necessary with gluten-free Montina™ foods. Potatoes, potato starch, potato flour Quinoa This flour can be substituted for regular flour to make Rice any gluten recipe such as cookies, cakes, gravy, Rice bran dumplings, pancakes, etc. Sago flour Sorghum Soy (soya) Tapioca Teff Wild rice

Oats: Oats themselves are naturally gluten-free. Oats are a whole grain so they possess important vitamins, minerals, and fiber that might be lacking in a gluten-free diet. Studies show that pure, uncontaminated oats are tolerable in moderation: 1/2 cup to 1/3 cup dry rolled oats for adults, and 1/4 cup for children(3) However, commercial oat products can be contaminated with wheat if they are processed or stored in a facility that processes wheat. Look for a certified gluten-free label if you are purchasing an oat product.(3) Grains to avoid Questionable ingredients Barley The following is a list of ingredients that are questionable and should Barley malt/extract not be consumed unless you can verify that they do not contain or Bulgur are not derived from gluten-containing grains: • Brown rice syrup (can be made from barley) Couscous • Flour or cereal products Durum • Hydrolyzed vegetable protein (HVP), hydrolyzed plant protein Einkorn (HPP), or textured vegetable protein (TVP) from a gluten- Emmer containing source Farina • Malt vinegar (distilled vinegar is ok) Faro • Modified food starch from a gluten-containing source Graham flour • Rice malt • Seasonings or “natural flavors” Kamut • Soy sauce, soy sauce solids, or teriyaki sauce Matzo flour/meal Orzo Frequently overlooked foods that often contain gluten: Panko • Breading • Licorice Rye • Brewer’s yeast • Marinades Seitan • Broth • Playdough Semolina • Brown rice syrup (wash hands after use) Spelt • Coating mixtures • Processed meats (deli meats, • Communion wafers Triticale salami, bologna, hot dogs, • Croutons lunch meats) Udon • Salad dressings • Roux Wheat • Drugs or over-the-counter • Sauces, gravies Wheat bran medications • Soup base/bouillon Wheat germ • Energy bars (see label) • Self-basting poultry Wheat starch • Herbal or nutritional supplements • Soy sauce, soy sauce solids • Ice cream or gelato • Thickeners • Imitation bacon and seafood • Veggie burgers

Where to shop for gluten-free foods In the past, gluten free products where found at specialty stores; luckily this has changed. Most national and regional grocery chains stock gluten-free foods, often in a special aisle or section but often located with other foods.

Regionally in Ohio, gluten-free foods can be found at Costco, Giant Eagle, Kroger, Meijer, Acme, Buehler’s, ALDI , Marc’s, Whole Foods, Trader Joe’s, Earth Fare, Mustard Seed, and Heinen’s.

Shopping tips • The perimeter of your supermarket mostly contains naturally gluten-free and nutritious foods like fruits, vegetables, meat, fish, and poultry, and dairy products • Don’t be afraid to ask store managers or staff if a particular item is GF! • READ LABELS! Avoid items with ingredients in the lists of non-GF ingredients provided here. • Look for labels on food packages to ensure they are gluten-free. You can find a variety of GF labels by doing a Google™ image search for “gluten-free labeling.” A note on gluten-free foods While there are a lot of gluten-free packaged and convenience foods on the market now, these aren’t necessarily the healthiest choices. Remember, gluten-free doesn’t automatically mean nutritious! These foods can have higher amounts of sugar, fat, and sodium, and lower fiber content. It is important to check the ingredients and make healthy choices. Here are some tips:

• Choose gluten-free foods that are made from whole grains, like brown rice or quinoa instead of white rice or corn flour. • The first ingredient on the label will be the most abundant in the food, so make sure that it is a gluten- free whole grain. • If you make a gluten-free pizza or pasta dish, load it up with vegetables and lean protein. • Watch out for gluten-free frozen meals – like all frozen meals, they can be loaded with sodium. • Save the GF snacks and desserts for special occasions (remember, moderation is key!) Here are a few gluten-free favorites:

o Tinkyada® gluten-free brown rice pasta (never mushy!) o Rudi’s® and Udi’s® gluten-free products (breads, bagels, pizza crust, etc.) o Lundberg® rice and quinoa products (most are GF, check label) o Bob’s Red Mill® Gluten-Free milled flours (offers a variety of flours for your baking and cooking needs) o Bob’s Red Mill® Gluten-Free Whole-Grain Rolled Oats or Gluten Freeda’s® Instant Oatmeal packets o Van’s Gluten-Free Foods® (Try the waffles. Many of the products are made with whole-grains.)

Reading labels On August 2, 2013, FDA issued a final rule defining “gluten-free” for food labeling with a compliance date of August 5th, 2014. This meant that food products bearing a gluten-free claim labeled on or after that date must meet the rule’s requirements. This allows consumers, especially those living with celiac disease, to be confident that items labeled “gluten-free” meet a defined standard for gluten content. Additionally, on June 25, 2014, FDA issued a guide for small food businesses to help them comply with the final rule’s requirements. For more information and FAQs regarding these changes please see: http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/Allergens/ucm362880.htm

Tips while dining out • It is more useful to ask if a food has any ingredient that is derived from or processed with wheat, barley, or rye, than to ask, “Is this food gluten-free?” • Salads can be tricky – make sure croutons never came in contact with the salad, and check ingredients of salad dressings. • Soups are often times thickened with flour, and can be another tricky menu selection • The following words on a menu may signify a gluten-containing item: hollandaise sauce, slurry, dredge, stock, chowder, torte, “cream of,” flourless cake, white sauce, mousse, and crème brûlée. Question the following cooking methods: braised, stewed, roasted, broiled, broasted, and grilled. • Foods that are deep fried need to be fried in a separate fryer dedicated to GF foods – ask your server how the food is fried (i.e., French fries, onion rings, fried chicken, hash browns, and tortillas and tortilla chips). • Burgers (including veggie burgers) can often contain fillers that contain gluten – please check. • Be courteous, but remind your server or chef that you have strict dietary needs. If it is helpful, you may be able to order restaurant cards that explain GF requirements to cooks. The cards might look like this: Example GF requirements card

To my server and/or chef: Please note: I have celiac disease and therefore have special dietary restrictions. I strictly cannot eat foods containing or that have come in contact with wheat, barley, rye, and oats (unless oats are certified gluten-free) or else I will become very sick. The foods I must avoid are:

• Gluten • Wheat • Flour • Bread, breading, bread crumbs, or batter • Pasta • Beer or malt beverage

If you are uncertain whether or not a particular food is gluten-free, please tell me before serving it to me. Thank you for your help.

WHEAT-FREE DOES NOT ALWAYS MEAN GLUTEN-FREE

Menu Items That Indicate Wheat Is Included

Menu Item Description Au gratin Browned topping of bread crumbs or grated cheese Bechamel White sauce made with a roux and milk for thickening Beurre manie Mixture of butter and flour used to thicken sauces Cordon bleu Chicken or veal and ham and cheese; breaded and sautéed Encrusted Flour or bread crumbs used to combine food items Dust Light shake over of dry ingredients, which may include flour Farfel Minced noodle dough used for soup Fricassee Meat or poultry stew thickened with flour Fritter Food dipped or mixed with batter and fried Gnocchi Dumplings made from a flour or potato/egg paste Pan gravy Sauce made from meat juices with flour added Marinade Soy sauce may be an ingredient Meuniere Sprinkled with flour and browned in butter Raspings Very thinly shredded stale bread Roux Butter and flour paste used to thicken sauces and soups Scallopini Thinly sliced meat cooked in fat to tenderize or coated in flour and fried Soy sauce Sauce made from fermented soy beans and may be roasted in wheat or barley Teriyaki sauce Contains soy sauce Tempura Shrimp, seafood, and vegetables battered and fried in a flour-based batter Velouté Sauce thickened with flour and used for soups, stews, and fricassee Welsh rarebit Cheese sauce made with ale or beer and served on toast or crackers Medications The following is a list of vitamin and mineral supplement brands with mostly all GF products. Please read all ingredient labels to ensure products are gluten-free.

• Freeda® Vitamins • Nature Made® • Solgar® • Twin Lab® • Whole Foods 365® Vitamins

These ingredients in supplements are gluten-free: • Cellulose • Medicinal alcohol • Caramel (usually derived from burnt sugar) • Lactose

Ingredients in supplements which are more likely to contain gluten: • Starch • Dusting powder • Pregelatinized starch • Flour

Ingredients in supplements which are less likely to contain gluten: • Sodium starch glycolate • Caramel coloring • Maltodextrin

Alcohol The following alcoholic beverages do not contain gluten and are therefore safe on a gluten-free diet:

• Distilled alcoholic beverages (i.e., gin, rum, vodka, whisky) • Wines and pure liqueurs • Gluten-free beer– These are now available but check label to ensure that it is certified GF.

Alcoholic beverages that do contain gluten because they were fermented from gluten-containing grains:

• Wine coolers • Most beers (unless specified as GF) • Ales • Lagers Resources Online Gluten-Free Food Resources Associations/Foundations Amy’s Kitchen American Celiac Disease Alliance www.amys.com www.americanceliac.org/celiac-disease Bob’s Red Mill 2504 Duxbury Place bobsredmill.com/gluten/php Alexandria, VA 22308 703.622.3331 Gluten-Free Mall www.glutenfreemall.com Celiac Disease Foundation www.celiac.org Gluten Solutions 13251 Ventura Blvd., #1 www.glutensolutions.com Studio City, CA 91604 Orgran Foods Phone: 818.990.2354 www.orgran.com E-mail: [email protected] Young & Gluten-Free National Foundation for Celiac Awareness www.youngandglutenfree.com www.celiaccentral.org P.O. Box 544 Books on Celiac Disease Ambler, PA 19002-0544 Celiac Disease: A Hidden Epidemic 215.325.1306 by Peter Green & Rory Jones E-mail: [email protected] Living Gluten-Free for Dummies Magazines by Danna Korn Gluten-Free Living: A magazine for people with Gluten-Free Diet: A Comprehensive Resource Guide celiac disease by Shelley Case Ann Whelan, Editor/Publisher P.O. BOX 375 The First Year: Celiac Disease and Living Gluten-Free Maple Shade, NJ 08052 by Jules E. Dowler Shepard 800.324.8781 Kids with Celiac Disease: A Family Guide to Raising www.glutenfreeliving.com Happy, Healthy, Gluten-free Children Sully’s Living Without: A magazine for people with by Danna Korn food allergies, intolerances, and sensitivities, including celiac disease References 800 Connecticut Avenue 1. Ediger TR, Hill ID. Celiac disease. Pediatr Rev. 2014;35:409-15. Norwalk, CT 06854 2. Barakauskas VE, Lam GY, Estey MP. Digesting all the options: 800.424.7887 Laboratory testing for celiac disease. Crit Rev Clin Lab Sci. www.livingwithout.com 2014;51:358-78. 3. Celiac Disease Foundation. Guidelines For A Gluten-Free Lifestyle. Enjoy Life Foods Woodland Hills, CA: Celiac Disease Foundation, 2009. Print. www.enjoylifefoods.com GFN Foods www.gfnfoods.com

Grocery Apps Shop Well Healthy Diet and Grocery Food Scanner Fooducate: Allergy and gluten free scanner Restaurant Apps Find Me Gluten Free—US Center for Human Nutrition, M17/ ican Eat Fast Food Gluten & Allergy App Digestive Disease Institute iEat Out Gluten & Allergy Free 9500 Euclid Avenue, Cleveland, OH 44195 Domestic and International Travel & Ethnic Foods Appointments: 216.444.3046 (Main Campus) 1.800.223.2273, ext. 43046 www.clevelandclinic.org/health/ This information is not intended to replace the medical advice of your health care provider. Please consult Produced by the Center for Consumer Health Information your health care provider for advice about a specific © The Cleveland Clinic Foundation 2017 10/17 medical condition. Index#15717